Transcript Title

EFFECTIVENESS OF QUALITY HEALTH CARE STRATEGIES IN IMPROVING SERVICE
DELIVERY AT THE NATIONAL REFERRAL HOSPITALS IN KENYA
Authors
DOUGLAS ODHIAMBO OWINO
[email protected]
And
DR MARY WANJIRU KINOTI
Contact
[email protected]
[email protected]
INTRODUCTION
This study investigated the effectiveness of quality health care strategies in
improving service delivery at the national referral hospitals in Kenya.
National referral refers to any process in which healthcare providers at lower levels
of the health system seek the assistance of providers who are better equipped or
specially trained to provide treatment and care of a patient.
According to WHO indicators on ranking of the overall performance of national
health systems and quality of health care varies in different countries.
Comparability of cross-national data is also a challenge and there is effort to
develop and validate quality indicators that can be used internationally (Rand,
2010).
INTRODUCTION Cont..
The Kenya’s health care provision and implementation infrastructure include the
National Referral and Teaching Hospitals, Provincial, District and Sub-District
Hospitals, Health Centres, and Public Dispensaries.
Health services are provided through a network of over 4,700 health facilities
countrywide.
The public sector system accounting for about 51 percent of these facilities
(Government of Kenya (GoK), 2005).
The rationale for measuring quality health care strategies is to establish the link in
to quality service delivery and hence good health care performance.
LITERATURE REVIEW: Theoretical foundations of the study
Total Quality Management (TQM) has been identified both as a model for good
management and;
 a theory of change with emphasis on continual improvement (Zadry & Yusof,
2009).
TQM has been recognised and used during the last few decades by organisations
all over the world to develop a quality focus and improve organisational
performance (Zadry & Yusof, 2009).
ISO 9001 Quality Management System standard have been adopted by
organisations to realise changes in organisational outcomes such as profits (Levine
& Toffel, 2010) .
Strategies for Quality Improvement
Quality improvement strategies are innovative, interdisciplinary movement aimed
to transform entrenched attitudes, practices, and management styles (Jennings et
al., 2007).
In some countries, performance-based payment programmes are an increasingly
common strategy for motivating quality improvement (Friedberg et al., 2010).
Quality-based payment pioneers are using a variety of incentive structures, and
are tapping a rich mix of structural, process, and outcome standards to
benchmark quality (McNAMARA, 2005).
Quality health care and reduction in healthcare disparities is an equally important
policy goal to most developing countries like Kenya (Friedberg et al., 2010).
Measurement of Quality in Healthcare Services
Healthcare quality measurement has long been the biggest hurdle in deciding
what to measure and how to measure it (Ilminen, 2003).
Debates in healthcare quality forums have shifted in recent decades from whether
quality can be measured to how best to measure quality in health care (Boyce,
1996).
Structures, process and outcomes measures can be used to determine
effectiveness of quality health care strategies.
These include follow-up systems, feedback mechanisms, time taken to serve
clients, re-admission rates, average rates of mortality, length of in-patient stay,
and level of client satisfaction with services provided by the hospitals.
Conceptual Framework
Improved service delivery at the national referral hospitals depends on adoption of
appropriate quality health care strategies
This can be established through structural, process and outcome measures in the
health delivery system.
Structural measures involve follow-up systems and adequacy of facilities.
Process measures include timeliness of care provided to patients.
Outcome measures include mortality rates, readmission rates, length of stay, health
status, and satisfaction with care.
Effective quality health care strategies is likely to improve quality of service delivery,
treatment and care of patients, and ultimately better clinical outcomes.
Figure on conceptual framework: Source: Researcher 2014
Independent Variables
Quality Healthcare
Strategies:
1. Quality
Management
Standards &
Systems
2. Strategic
Leadership
Training
3. ICT
innovations
4. ResultsBased
Financing
e.t.c.)
Intervening Variables
Dependent variable
Structural
Measures
Process
Measures
Outcome
Measures
Improved
Quality in
Healthcare
/Better
Clinical
Outcomes
RESEARCH METHODOLOGY
Descriptive survey design was used to describe and portray characteristics
of the population of the study.
The population of this study comprised two national referral hospitals in
Kenya, namely Kenyatta National Hospital and Moi Teaching and Referral
Hospital.
The two hospitals have a total of 96 departments and units performing
clinical and administrative functions.
Due to the small sample, a census survey was conducted
RESEARCH METHODOLOGY Cont..
Primary data which comprised both quantitative and qualitative data was
collected using semi-structured questionnaire.
The questionnaire was pre-tested to refine and improve based on the
respondents’ feedback.
This was to ensure that the validity and reliability of the data collected
(Saunders et al, 1997).
Data were collected from:
 heads of departments and units, and;
 in-charges of various wards and the questionnaires were selfadministered.
RESEARCH METHODOLOGY Cont..
 To analyze the data, descriptive and correlation statistical analysis were
used.
 Prior to analysis each questionnaire was coded and data entered in in
SPSS version 17.0.
 Qualitative data was subjected to content analysis to test theoretical
issues to enhance understanding and analysis of data
FINDINGS OF THE STUDY AND DISCUSSIONS
Background Information of the Respondents:
Data collected on background information included type of department, number
of respondents in terms of hospital functions, and;
 Number of staff segregated in terms of medical and non-medical staff.
Majority (20.9%) of the respondents were from units under medicine, followed
by Private Wing (10.4%), Mental Health (10.4%) and Surgery (9.0%)
Department
Medicine
Reproductive Health
Surgery
Orthopedic
Pediatrics
Accident and Emergency
Dental Services
ENT
Radiology
Renal
CCU
Private Wing
Ophthalmology
Physiotherapy
Palliative Care
Mental Health
Patient Affairs
Not indicated
ICT
Finance
Administration
Laundry
Telephone
Human Resource
Corporate Affairs
Supply Chain Management
Technical Services
Risk and Audit
Risk and Quality
Total
Frequency
14
3
6
3
1
3
1
1
1
2
1
7
1
1
1
7
1
2
1
1
1
1
1
1
1
1
1
1
1
67
Percent
20.9
4.5
9.0
4.5
1.5
4.5
1.5
1.5
1.5
3.0
1.5
10.4
1.5
1.5
1.5
10.4
1.5
3.0
1.5
1.5
1.5
1.5
1.5
1.5
1.5
1.5
1.5
1.5
1.5
100.0
Number of Respondents In Terms of Hospital Functions
According to the findings, 83.58% of the respondents were from clinical
functions and;
 16.42% were from administrative services of the hospitals.
Clinical care and treatment is the core function of the national referral hospitals
as represented by the majority of the respondents
Table on number of Respondents In Terms of Hospital Functions
Clinical Services
Administrative Services
Total
Frequency
56
11
67
Percent
83.6
16.4
100.0
Quality Healthcare Strategies for Improving Service
Delivery
The study also investigated various quality healthcare strategies adopted by
the hospitals to improve their systems and processes which involved:
 Training of staff in strategic leadership,
Results-Based Financing (RBF),
Adoption of ICT and;
 Quality management systems and standards.
Strategic Leadership Training
According to the findings 32.8% of the respondents considered strategic
leadership training as very successful,
32.8% somewhat successful and;
 11.9% highly successful.
Only 4.5% of the respondents indicated that it was unsuccessful.
Therefore, it can be presumed that training of hospital managers on strategic
leadership was successful in improving service quality at the two national referral
hospitals.
Table on Success of strategic leadership training in improving service delivery
Highly Successful
Very Successful
Somewhat Successful
Unsuccessful
Not implemented
Non-response
Total
Frequency
8
22
22
3
6
6
67
Percent
11.9
32.8
32.8
4.5
9.0
9.0
100.0
Hockey and Marshall (2009) also found out that educational interventions to improve
quality of care are effective, and;
That in future it will not be possible to be an effective clinician without both a theoretical
and a practical understanding of the science of quality improvement
Results-Based Financing
The findings on RBF showed that, 47.8% of the respondents who implemented
Results-Based Financing consider it somewhat successful,
 16.4% very successful and 4.5% indicated that it was highly successful
However, 13.4% considered RBF unsuccessful.
This implies that RBF was successful in improving service delivery systems and
processes, leading to improved service quality.
Table on success of results-based financing in improving service delivery
Highly Successful
Very Successful
Somewhat Successful
Unsuccessful
Not implemented
Non-response
Total
Frequency
3
11
32
9
7
5
67
Percent
4.5
16.4
47.8
13.4
10.4
7.5
100.0
A report by Open Health Initiative (2012) noted that RBF motivates healthcare
workers to provide comprehensive and quality services,
However, RBF is difficult to maintain when the economy or local healthcare market
declines, and cutbacks are often necessary (Caroll, et. al, 2007).
Therefore, RBF alone may not be relied on for service delivery improvement at the
hospitals.
Adoption of ICT
The study investigated the extent to which ICT is considered successful in
improving service delivery at the national referral hospitals in Kenya.
The findings showed that 53.7% somewhat successful,
 22.45 very successful and 4.5% considered adoption of ICT highly
successful.
 On the other hand, 7.5% of the respondents considered adoption of ICT
as unsuccessful.
 Another, 6.0% of the respondents did not adopt ICT and they indicated
that their operations were not automated.
 It is apparent that application of ICT to improve Hospitals’ service
delivery system was successful.
Table on success of ICT adoption in improving service delivery
Highly Successful
Very Successful
Somewhat Successful
Unsuccessful
Not implemented
Not indicated
Total
Frequency
3
15
36
5
4
4
67
Percent
4.5
22.4
53.7
7.5
6.0
6.0
100.0
The findings conform to the reviews done by British Columbia Medical
Association in 2006 on how IT reduced waiting times, particularly time taken
to see a specialist.
Therefore, adoption of ICT can drastically reduce turnaround time if fully
adopted in the operations of the hospitals.
Quality Management Systems and Standards
According to findings, 38.81% of the respondents felt adoption of Quality
Management Standards was very successful,
31.34% somewhat successful and;
 20.9% indicated that it was highly successful.
 It is possible to conclude that adoption of QMS was successful in improving
quality of services provided by the hospitals.
Table on success of Quality Management Standards and Systems in improving service delivery
Highly Successful
Very Successful
Somewhat Successful
Non-response
Total
Frequency
14
26
21
6
67
Percent
20.9
38.8
31.3
9.0
100.0
The findings are corroborated with Heuvel (2001) who observed that integrating ISO and Six
Sigma in a hospital operations yielded benefits
Such as an excellent document control system, an increase in production and a decrease in
costs resulting to improved efficiency.
Other Quality Improvement Strategies
In addition to key strategic interventions in improving service delivery,
20.9% of the respondents also indicated that they have put in place other quality
improvement programmes to improve their services.
These included implementation of GEMBA 5S KAIZEN, Kenya Quality Model for
Health (KQMH), clinical audits, use of protocols and on-job training.
 According to the findings, 50% felt that specific interventions at departmental level
was very successful,
29% indicated that the interventions were highly successful, and 21% felt that the
interventions were somewhat successful.
Berenson, et. al (2013) also observed the need to use quality measures strategically
by adopting other quality improvement approaches where measures fall short.
Effectiveness of quality healthcare strategies on service
delivery systems and processes
The findings showed a perfect positive relationship between the quality
healthcare strategies and service delivery systems, and processes.
Although varying degrees of relationship between independent and
dependent variables was noted.
The relationship between application of ICT and follow-up systems was very
significant compared to other strategic interventions.
This conforms to the findings of MEDPAC report (2004) that showed that
application of ICT provides new ways for health care providers and patients to
readily access and use health information, thereby improving the quality,
safety, and efficiency of healthcare.
Relationship between quality healthcare strategies and service delivery systems, and processes
Dependent Variables
Independent variables
Follow up
systems
Feedback
to clients
Time
taken to
admit
patients
Time
taken to
attend to
walk-in
patients
Time
Taken to
discharge
patients
Strategic Leadership Training
.207
.748
.875
.302
.946
Results Based Financing
.296
.675
.734
.535
.835
ICT adoption/innovation
.829
.231
.348
.225
.003
Quality Management Standards
and Systems
.005
.018
.434
.316
.288
Other Quality Improvement
Initiatives
.300
.799
.201
.528
.207
Effectiveness of quality healthcare strategies on service
delivery systems and processes Cont..
 Strategic Leadership Training, RBF and specific strategic interventions by the
departments showed a higher significant relationship with time taken to
provide feedback to clients.
Time taken to attend to walk-in patients had a stronger positive relationship
with RBF and specific strategic interventions by the departments.
Time taken to admit and discharge patients had a higher significant
relationship with RBF and strategic leadership training.
Most promising organisational changes in healthcare delivery require
collective, coordinated behavior change involving quality improvement
programs and patient safety systems (Weiner (2009).
Financial incentives directed at health system level have can cause positive
effect on quality of care and treatment (Brook et.al.,2000).
Effectiveness of quality healthcare strategies on improving
service delivery outcomes
The findings showed a perfect positive relationship between quality healthcare
strategies and service delivery outcomes.
These included re-admission rates, average rates of mortality, infection rates,
length of in-patient stay, time taken to serve clients, average waiting time and level
of client satisfaction with services provided by the hospitals.
Strategic Leadership Training, RBF, and quality improvement interventions at the
departmental level had a high significant relationship with rates of readmission,
average mortality, and to lesser extent time taken to serve clients and average
waiting time to be served.
The quality healthcare strategies adopted by the hospitals had a positive effect on
average rate of infection, albeit with minimal difference in the degree of
relationship.
Relationship between quality healthcare strategies and service delivery outcomes
Independent
variables
Dependent Variables
Infecti
Lengt
Time
Time
on rate
h intaken
taken
patie
to
to
nt
serve
serve
stay
intern
extern
al
al
client
clients
s
.145
.650
.343
.310
Readmissi
on rate
Mortali
ty rate
Strategic
Leadership
Training
.974
.856
Results Based
Financing
.677
.816
.229
.824
.379
ICT
adoption/innovat
ion
.187
.012
.236
.529
Quality
Management
Standards and
Systems
Other Quality
.497
.351
.105
.971
.656
.380
Improvement
Initiatives
waitin
g time
Level of
client
satisfacti
on
.403
.265
.392
.422
.034
.037
.046
.035
.975
.719
.005
.005
.007
.146
.778
.305
.261
.298
.784
Effectiveness of quality healthcare strategies on
improving service delivery outcomes Cont..
Strategic interventions at the departmental level and rates of infection indicated a
slightly significant relationship compared to other study variables.
The strategies adopted by the hospitals had a very significant relationship with
average length of in-patient stay.
Application of ICT and specific strategic interventions by the departments had a
higher significant relationship with the level of client satisfaction.
Interventions to improve service quality dimensions and customer satisfaction are
significantly related (Agbor, 2011).
Participation in leadership programmes catalysed improvements in hospitals
(Health Foundation report, 2012).
Critical Drivers of Quality Improvement
Majority of the respondents indicated that strategic plan (71.7%), service delivery
charter (79.1%), vision (74.6%) and mission (76.1%) were useful in improving
delivery of services in the hospitals.
Other critical drivers were:
 Quality audits
 Staff commitment
 Quality assurance circles which involved formation of quality improvement
teams at all levels in the hospitals to drive the strategic interventions
.
Other critical drivers
Driver
Percentage response
Quality Audits and implementation
29%
Staff commitment
22%
Sensitisation and training
19%
Quality assurance circles
15%
Management commitment
9%
Availability of necessary supplies/facilities
4%
Adoption of ICT applications
2%
Case studies of four hospitals revealed that a trigger by multidisciplinary teams, qualityrelated committees, and technology investments facilitated a systematic problemidentification and problem-solving process,
Resulting in new treatment protocols and practices, which in turn result in improved
outcomes ( Silow-Carroll et. al.,2007).
Discussion of findings
Different quality improvement strategies had varying degrees of relationships with
structural, process and outcome measures.
Therefore, quality improvement at the national hospitals requires a multifaceted
approach targeting all functions, and;
 Adoption of appropriate model for implementation of the strategies.
The model should address the unique characteristics of various institutions to
determine the best fit when selecting quality improvement programmes.
Model for implementation of quality healthcare strategies
Identify appropriate
strategic intervention (ICT
innovations and
applications, Strategic
Leadership Training,
Evaluate
effectiveness of
QIPs
Quality Management
Standards and Systems,
Results-Based Financing
e.t.c.
Structural
measures
Assess fit with
organisational strategic
intent
Implement selected QIP(s)
Source: Researcher, 2014
Process
measures
Outcome
measures
Better clinical
outcomes/
Enhanced Service
Delivery Systems
Improved
Customer
satisfaction
Discussion of findings Cont..
Holistic approach that focuses on standards, resources and people is required to
ensure positive results at all levels in the hospitals’ service delivery system.
Improving quality of care services in resource poor settings as in the case of the
two national referral hospitals,
 Requires concerted effort and the need to address the challenges through
appropriate interventions aimed at organisational transformation.
RECOMMENDATIONS FOR POLICY, THEORY AND PRACTICE
The Government should consider developing a policy to institutionalise
adoption of Quality Improvement Programs (QIPs) in public hospitals in the
country.
In addition, quality management should form part of core curriculum for health
workers and should be made a mandatory requirement for healthcare
managers.
For sustainability of this policy initiative, quality improvement programmes
should be integrated in the performance management in various public
hospitals.
The Government should consider developing national accreditation framework
for both public and private hospitals to assure quality healthcare at the national
and county level.
LIMITATIONS OF THE STUDY
This study was limited to two published national referral hospitals in
Kenya (KNH and MTRH).
However, there are other referral hospitals in various counties.
The study was conducted between February and April, 2014.
RECOMMENDATIONS FOR FURTHER RESEARCH
Further study is required on appropriate strategic interventions to improve
clinical outcomes.
This study focused on effectiveness of various quality healthcare strategies on
the hospitals’ service delivery systems, which has shown varying degree of
results.
However, the ultimate goal of healthcare providers is to realise better clinical
outcomes.
Therefore, a further study is required to identify specific strategic interventions
that can be used to enhance service quality and optimise clinical outcomes in
public hospitals in Kenya.
REFERENCES
Agbor,J.M. (2011). The Relationship between Customer Satisfaction and Service Quality:
a study of three Service sectors in Umeå. Umeå School of Business.
American Heart Association. (2000). Measuring and Improving Quality of Care.
Journal of the American Heart Association, 101, 1483-1493.
Barouch,P.G. (2011). Total Quality Management as a Theory of Change. Total Quality
Management & Excellence, 39, (2), 2011.
Berenson et. al (2013). Achieving The Potential Of Health Care Performance Measures:
Timely Analysis Of Immediate Health Policy Issues. Urban Institute
British Columbia Medical Association (2006). Waiting Too Long: Reducing and Better
Managing. Wait Times in BC. BCMA
Boyce, N. (1996). Using Outcome Data to Measure Quality in Health Care. International
Journal for Quality in Health Care.8, (2), 101-104.
Brook, et al.(2000). Defining and measuring quality of care: A perspective from US
researchers. International Journal for Quality in Health Care, 12, (4), 281-295
REFERENCES
Burton, D. (Ed.). (2000). Research training for social scientists: a handbook for
postgraduate researchers. London, Sage.
Carroll, et. al. (2007). Hospital Quality Improvement: Strategies And Lessons
From U.S. Hospitals. Commonwealth Fund.
Elo, S., & Kyngas, H. (2008). The qualitative content analysis process. Journal of
Advanced Nursing 62(1), 107–115. Accessed on 28/08/2013 from doi: 10.1111/j.1365-2648.2007.04569.x
Franks. O.S.W.(2009). A Theoretical Model for Implementing Quality Management in an
Automated Environment. International Journal of Control and Automation, 2, (2)
Friedberg et al. (2010). Paying For Performance In Primary Care: Potential Impact On
Practices And Disparities. Health Affairs, 29,(5), 926-932 accessed on
25/08/2013 from doi: 10.1377/hlthaff.2009.0985
Government of Kenya. (2010). Kenya Health System Assessment 2012. Nairobi:
Government printer.
REFERENCES
Health Foundation. (2012). Overcomingchallengesto improvingquality.Lessons from the
Health Foundation’s improvement programme evaluations and relevant
literature. Health Foundation, London
Hockey,P.M., & Marshal, M.N. (2009). Doctors and Quality Improvement. Journal of
the Royal Medicine, 102, 173-176.
Iminen, G.R. (2003). Quality in Healthcare: Improving Healthcare measurement.
Accessed on 21/07/2013 from www.asq.org.
Jennings et al. (Ed.). (2007). Quality Improvement: Ethical and Regulatory Issues. The
Hastings Center Garrison, New York.
Levine, D.I., &Toffel, M.W. (2010). Quality Management and Job Quality: How the ISO
9001 Standard for Quality Management Systems Affects Employees and
Employers. Working paper, Harvard Business School.
REFERENCES
McNAMARA, P. (2005). Perspectives on Quality Quality-based payment: six case
examples. International Journal for Quality in Health Care, 17,(4), 357–362
Accessed on 02/05/2013 from http://intqhc.oxfordjournals.org/.
MEDPAC. (2004). Information Technology in health care. Report to the Congress: New
Approaches in Medicare
North Carolina Institute for Public Health. (2008). Opportunities to Advance Quality
Improvement in Public Health. Accessed on 15/07/2013 from
http://nciph.sph.unc.edu.
Open Health Initiative (2012).The Open Health Initiative to Improve Reproductive,
Maternal,Newborn, and Child Health in the East African Community Partner
States. Arusha
O’Reilly et.al. (2010). How leadership matters: The effects of leaders’ alignment on
strategy implementation. The Leadership Quarterly, 21, 104-113
REFERENCES
RAND. (2010). International Benchmarking of Healthcare Quality. RAND and London
School of Hygiene and Tropical Medicine
Saunders et al. (1997). Research Methods for Business Students.
Edinburgh Gate: Pearson.
Shah, A (2013). Health Care Around the World. Global Issues. Accessed on 17/092013
from<http://www.globalissues.org/article/774/health-care-around-the-world.
Turin,D.R. (2010). Health Care Utilization in the Kenyan Health System: Challenges and
Opportunities. Accessed on 13/06/2013 from http://www.studentpulse.com.
Wamai, R.G. (2009). The Kenyan Health System: Analysis of the Situation and enduring
challenges. JMAJ, 52(2),134-140.
WHO. (2003).Quality and accreditation in health care services: A global review.
WHO, Geneva, Switzerland.
REFERENCES
Weiner, B.J. (2009). A theory of organizational readiness for change. Implementation
Science, 4(67)
Zadry, H.R., & Yusof, S.M. (2006). Total Quality Management and Theory of
Constraints Implementation in Malaysian Automotive Suppliers: A Survey
Result.Total Quality Management, 17 ( 8), 999–1020
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